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General NPI Number Information
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NPI Number | 1821243239
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Entity Type | Organization
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Legal Business Name | FIFTH AVENUE OF EDINA INC.
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Dates
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Enumeration Date | 11/26/2008
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Last Update Date | 06/13/2012
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Provider Practice Location Address
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Address Line | 3540 GALLERIA
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City | EDINA
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State | MN
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Zip | 55435-4218
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Country | US
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Telephone | 952-922-1052
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Fax | 952-922-2518
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Provider Business Mailing Address
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Address Line | 3540 GALLERIA
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City | EDINA
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State | MN
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Zip | 55435-4218
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Country | US
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Telephone | 952-922-1052
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Fax | 952-922-2518
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Authorized Official
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Title or Position | OWNER
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Name | GALE L STEAD
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Credential | O.D.
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Telephone | 952-922-1052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1456
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 1456
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License Number State | MN
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